CPR

Advances in modern emergency medicine and critical care are amazing. Previously unsalvageable patients may be rescued, thanks to both attention to detail for the basics (FAST HUGS IN BED) and advances in ventilation, inotropic support, antimicrobial therapy and technology such as extra-corporeal membrane oxygenation (ECMO).

The latter has attracted some recent attention, especially in regard to management of cardiac arrest; rather than simultaneously diagnose and treat the causes (4Hs, 4Ts) of a failed heart in cardiac arrest management, putting the patient on VA-ECMO allows maintenance of oxygenation and perfusion. Not surprisingly, there is lots of discussion in prehospital fora on bringing early ECMO to patients undergoing cardiac arrest.

One recent comment on Twitter caught my eye – the notion that ECMO was the panacea to the currently poor survival rates from cardiac arrest

Whilst technological advances such as ECMO can appear attractive, I think a focus on such expensive technology kind of misses the point. We see similar situation in prehospital trauma care – it’s all very exciting to focus on retrieval services with helicopters, prehospital REBOA and so on – but as trauma guru Karim Brohi said to me at an Australian Trauma Society meeting “it’s better to be the fence at the top of the cliff, than the ambulance at the bottom”

All of which is a long-winded way of reminding primary care practitioners that they DO have a role to play in critical illness – with prevention better than cure! The work of the GP is not as glamorous as the trauma specialist or cardiac surgeon. But it’s here in the simple interactions everyday during a GP consult that lives can be saved – initiating conversations about lifestyle, encouraging healthy diet and exercise, measuring and treating obesity, hypertension, hypercholesterolaemia. These are obvious goals.

What’s not so obvious are taking the same preventative health measures out to the community. Running outreach clinics for mental health, Pap smears and talking to sports clubs about drink-drug driving, wearing seatbelts, farm safety etc are also vitally important (although rarely remunerated).

The Scourge of Cardiac Arrest in Australia

Cardiac arrest is indeed low hanging fruit. There are an estimated 30,000 cardiac arrests per annum in Australia. But survival rates from cardiac arrest remain poor, especially for out-of-hospital cardiac arrest (OOHCA), with only 9-10% surviving.

Think about what happens when someone collapses in the street, cafe or shop today. Passersby may or more likely, may not be comfortable in starting CPR. A call is made to ambulance via 000 (can use 112 on mobile). The call is taken by an ambulance call operator who may guide the caller through CPR whilst simultaneously calling an ambulance. It is only with the arrival of trained ambulance officers that defibrillation is delivered (or CPR initiated if passersby have not started). For a CPR-qualified person in the immediate vicinity, the sound of the ambulance siren may be the first awareness that something is wrong…by which time their services are not needed.

“it’s pure luck whether a passerby is available & willing to deliver CPR or not”

Take Heart Australia

It is said that survival drops by 10% for every minute delay to definitive treatment (defibrillation for the most common cause of OOHCA, ventricular fibrillation).

Have a think about that. A ten percent drop in survival for every minute delay to defibrillation. Ambulance response times in the city are around 8 minutes for a priority one call – considerably longer in the bush. No wonder OOHCA survival is so poor.

But it doesn’t have to be this way. Some locations have got their collective act together; it is said that OOHCA survival rates in Seattle approach 62%. How? By ensuring that basic care is delivered early – via bystander CPR by trained community members and early defibrillation, often prior to arrival of the ambulance, through provision of public access automatic external defibrillators (AEDs).

Survival from cardiac arrest in Australia – 9%

Survival from cardiac arrest in Seattle – 62%

Many of you will have seen defibrillators in airports, shopping malls and sports stadiums. But how many of the community are confident to either perform CPR or to use an AED? In 2015 the Kangaroo Island medical students & myself visited the bowls clubs on Kangaroo Island and taught members how to perform ‘hands only’ CPR and practice use of the defib. I would love to extend this program still further and make my community on Kangaroo Island a ‘heart safe’ community. To do that requires several things

ensuring that as many of the community are trained in ‘hands only’ CPR as possible

ensuring that community members are prepared to use a defibrillator and that such AEDs are available and easily locatable

ensuring ready back up of lay responders, through existing emergency services (we already have a network of volunteers in ambulance, road rescue, fire, coastguard) as well as many others with Senior First Aid or other certification (Parks & Wildlife, Tour Operators, off duty medical and nursing staff etc)

Saving the newly dead – via disco!

So – the challenge for 2016 will be to train as many of the community as possible in ‘hands only’ CPR (this obviates the usual reluctance to get involved in a collapse and the requirement to perform a ‘kiss of life’ or expired air resuscitation). Hands only CPR to the beat of the Bee Gee’s ‘Staying Alive’ is the current paradigm for lay responders.

The notion of ‘hands only’ CPR is being made available through several public service messages. Omitting the need for breaths and using an easily remembered beat (Stayin’ Alive) aims to deliver effective CPR to as many people as possible, rather than confuse lay responders with compression:breathing ratios and concerns over performing EAR on an unknown patient, possibly with blood or vomit in their mouth.

American physician and comedian Ken Jeong shows the US audience how to ‘save a life with disco’ here :

Whilst former footballer, hardman and UK actor Vinnie Jones hams it up for a UK audience here :

Community responders could comfortably manage the first four steps of the ‘chain of survival’ shown below (image from Take heart Australia website)

There is no doubt that training of community members is achievable – and delivering ‘hands only’ CPR is better than doing nothing until the ambulance arrives! There are many training organisations out there already who can train individuals or groups in CPR (eg St Johns Australia, Surf Life Saving etc).

Many workplaces require a Senior First Aid certificate for employ…and of course there is a pool of people who regularly train in CPR (off duty emergency service personnel, tour operators, parks & wildlife, teachers etc). But what’s the point of being able to deliver CPR unless the person drops dead in front of you? Some sort of activation system is needed…

Coordinating responders – use the power of smartphone in your pocket!

Training responders in CPR is only part of the paradigm. Ambulance response times are still going to be significant in rural areas (volunteers have to come in from home/work in order to respond to an ambulance call) This is where I think crowdsourcing extra help will be a game-changer.

“Forget critical care technology such as ECMO – crowdsourced community CPR is the future to improve OOHCA survival“

A former medical school friend of mine, Mark Wilson and programming genius Ali Ghorbangholi have come up with the FREE GoodSAMapp for smartphones. Mark is a neurosurgeon and prehospital doctor, as well as a thoroughly nice chap (see him here explaining neurosurgery for everyone) :

Based in London, he was frustrated at the delay in delivery of simple measures (opening an airway, CPR) for patients before HEMS ambulance arrived. In a large city like London, you are probably never more than a few metres away from someone who is trained in CPR – but they may be in the shop next door, unaware. Wouldn’t it be great to be able to mobilise their skills prior to the arrival of ambulance and ensure early and effective CPR?

The premise is simple – modern smartphones contain GPS, maps, camera and communication capability (and so much more). Why not harness this power in your pocket to activate registered first aid providers, such as off duty paramedics, doctors, nurses, fire crew etc to respond to an out of hospital cardiac arrest? Good Samaritans – hence GoodSAM (Smartphone Activated Medics).

Two free apps – the Alerter and the Responder app are available; general public can download the Alerter app; registered first aid providers can download both Alerter and Responder apps.

The Alerter app is simple; using it activates emergency services using the appropriate number (999 in the UK, 000 in Australia) and the usual cascade of activation occurs. But the alerter app also allows geo-tagging of public access AEDs through the ‘defibrilocator’ function, as well as activating the GoodSAM network when used.

This is where the Responder app comes into play. Holders of a recognised CPR qualification (which might be off duty clinical staff and holders of a industry qualification such as Senior First Aid) can register as GoodSAM responders. By downloading the responder app, they will be alerted if there is a cardiac arrest in the immediate vicinity. If available, they can respond. If not, they can reject the notification and the next available GoodSAM responder is notified.

Both Alerter and Responder apps can be downloaded from the GoodSAM website for free.

Using the Alerter app does trigger both 000 and GoodSAM activations; ringing 000 direct just activates 000…meaning the CPR-qualified first aider next door may be oblivious of the incident until they hear the ambulance sirens…and chances of recovery are significantly reduced

Navigate to GoodSAM app – use tab indicated by the green arrow to download Alerter and Responder apps for various platforms

“Crowdsourced CPR – it’s kind of like Uber – but for cardiac arrest!”

The app is available for Android, iOS, and Windows. For those without a smartphone or poor reception, it also allows notification by text or an audible sound, showing the responder the precise location of an incident via GPS.

Crowdsourcing CPR via community responders not a replacement for ambulance by any means; rather it’s a social enterprise project to help deliver effective care such as CPR and defibrillation by registered and trained first aid responders when time critical.

London Ambulance have integrated GoodSAM into their Emergency Operations Centre, ensuring a request for ambulance triggers both London Ambulance as well as activating the GoodSAM network. I believe Sydney are looking at this also, and hopefully other Australian cities will follow suit.

Map of GoodSAM responders in Australasia – Uptake has mostly been with emergency staff in hospital…I’d love to encourage use of GPs, fire, SES, Surf Life Saving etc – indeed anyone who can verify credentials to provide CPR. GoodSAM registration provided with Senior First Aid certification perhaps?

For a small rural community, setting up a local GoodSAM responder group allows easy registration and activation of any and all first aid trained individuals (ambulance, fire, rescue, coastguard, surf-life saving etc). Group administrators are able to see available responders location on a map and send push notification messages within the group, adding to rural community resilience in an emergency.

“With the tyranny of distance in Australia, why would you not want to use such a system to mobilise any available help?”

Of course there are some concerns from naysayers. Some medics have been reluctant to register for GoodSAM, on the basis that they may be held liable if unable or unwilling to respond to a call for help. I find this perplexing – all primary care doctors undertake mandatory CPR training every triennium and use of GoodSAM seems s sensible way to harness their collective skills; especially if added to surf life savers, paramedics, nurses, coastguards, SES, CFS/MFS etc etc. Fears of being sued for not responding to an app activation seem like scaremongering – here in SA as part of the Rural Emergency Responder Network, registered doctors can choose to decline an emergency page if unavailable. Similarly rejecting a goodSAm alert just flicks it on to the next available responder – and of course, the network is voluntary and in a ‘Good Samaritan’ mode of operation – ambulance services are still activated via 000.

If my family member or loved one was unfortunate enough to have an out of hospital cardiac arrest, I would be glad that someone had at least attempted CPR rather than delay until ambos arrive. As the Australian resuscitation council make clear “any attempt at resuscitation is better than no attempt.” Similarly as a health professional, I would feel terrible if I was available to help and yet unaware of the incident until I heard the sirens and saw the ambulance arrive.

Australian emergency law expert Prof Michael Eburn runs an authoritative blog and has excellent commentary on Good Samaritan legislation and other matters for those who wish to examine Good Samaritan law in each State in more detail. For me, the benefits to community of being available to deliver CPR by a trained person far outweigh the risks. If medical professionals are worried about liability if turn down a request for help, same logic dictates they should never carry a phone….or even have clinic phone number advertised, lest someone ring for assistance!

Being able to crowdsource CPR for OOHCA by early activation prior to ambulance arrival – as such, free apps such as GoodSAMapp have much to offer!

I’d also be interested in ventures where training in CPR was offered at school and then updated throughout subsequent years – some have even suggested CPR certification needed to update drivers licence in Australia! They do this in Seattle! Take Heart Australia are advocating the same here.

Australian Resuscitation Council – The ARC is a voluntary co-ordinating body which represents all major groups involved in the teaching and practice of resuscitation.

GoodSAMapp – Good (S)martphone (A)ctivated (M)edics uses the latest technologies to alert those with medical training to nearby emergencies so that potentially life-saving interventions can be given before the arrival of emergency services. we aspire to have the highest levels of governance; all responders are checked, approved and their training is confirmed. The GoodSAM system is built such that individual organisations can administer their own Responders, then with local agreements, the statutory ambulance service can harness these Responders when there is a life critical emergency near them.

Tim Leeuwenburg

RESUSCITATE - DIFFERENTIATE - INVESTIGATE

I am a Rural Doctor on Kangaroo Island, South Australia with interests in emergency medicine, anaesthetics & trauma. When not working I enjoy fiddling with chainsaws and seakayaking. Along with partner Patricia we rehabilitate orphaned wildlife and devise roadkill recipes.